Lactation Consult Request Form

Home / Lactation Consult Request Form

I am*
- a parent, and live in South Kaipara
- a parent, and I have been cared for by a HBC Midwife
- a Health Care Professional. Please enter your contact details
- other
HCP name and contact details / 'other' explanation
First name
Last name
Address
Phone number
Email
Mother's Date of birth

Day
Month
Year
Mother's NHI number
Baby's name
Baby's date of birth

Day
Month
Year
Baby's NHI number
Reason for consult

Get In Touch